Medication protocols for emotionally challenged dogs during veterinary visits and procedures from Zero Pain Philosophy and Behavioural Referrals Veterinary Practice
This protocol is designed to be used in conjunction with a dog friendly approach to managing the individual patient. Emotional assessment of the patient should have been carried out as part of that management process. Where necessary advice regarding the emotional health of the patient through consultation with a veterinary colleague working in behavioural medicine may be sought.
PRE-VISIT COMPONENT OF PROTOCOL
Give oral anxiolytic at home 1-2 hours prior to visit. Options:
· Trazodone 4-8 mg/kg PO
OR
· Alprazolam 0.01-0.1 mg/kg PO
OR
· Diazepam 1-2 mg/kg PO
Give a trial of the therapeutic dose of the chosen drug several days prior to scheduled appointment and assess effect.
The use of benzodiazepines may be most appropriate when patients will benefit from potential amnesic effect of the medication in order to prevent negative memory formation which can be detrimental to future visits. With alprazolam a test dose of 0.01 mg/kg can be given first as those animals that react with agitation will often do so at the very low dose. If there is no reaction at the low dose you should then trial the therapeutic dose on a different day as some dogs do show a reaction at the higher dose.
Only in cases where the trial of a therapeutic dose of trazodone alone has been unsuccessful and/or the patient is particularly emotionally challenged by a veterinary visit it is possible to combine trazodone with gabapentin using the following recommended dose:
· Trazodone 4-12 mg/kg PO and gabapentin 20 mg/kg PO given at home 1-2 hours prior to visit
NB Gabapentin is a schedule 3 medication and subject to relevant prescribing regulations. For small dogs liquid preparations can facilitate administration of the medication and accuracy of dosing.
In situations where medications above are not appropriate for individual patient and / or cases where emotional arousal is a significant factor the use of noradrenergic acting medication such as Sileo® and Tessie® (according to manufacturers published dose rates) can be considered.
In cases where patients are attending consultations only or routine blood sampling the pre-visit component may be sufficient alone. For particularly challenged patients and those undergoing procedures it may be appropriate to combine with sedation protocols on arrival at the practice.
The presence of acute or chronic pain must always be considered as a potential factor when patients are exhibiting challenging behaviour. The use of gabapentin as part of the pre visit protocol may be of particular benefit for patients with a pain component, provided they are gabapentin naïve. The use of EMLA or cold spray preparations should be considered before embarking on procedures such as venepuncture.
ON ARRIVAL AT THE PRACTICE
Depending on level of sedation produced it may be then be possible to give an IM injection on arrival at the surgery of:
· 0.02 mg/kg medetomidine and
· 2 mg/kg ketamine and
· 0.2 mg/kg butorphanol
If unable to give IM injection despite oral anxiolytics at home give oro-transmucosal medetomidine at least 0.05 mg/kg. Once sedated give IM injection of
· 2 mg/kg ketamine and
· 0.2 mg/kg butorphanol
If after oral medetomidine the dog is really sedated then give IM injection at half those doses;
· 1 mg/kg ketamine and
· 0.1 mg/kg butorphanol
If conducting surgery, the butorphanol should be replaced with methadone at 0.2mg/kg.
Inclusion of a benzodiazepine at some stage is beneficial due to the retrograde amnesic effects. Options:
· Orally, as part of the at home option (as discussed above).
· Intramuscularly once sedative options discussed above have taken effect – midazolam 0.25mg/kg.
· Intravenously as part of the anaesthetic induction protocol. Give 1 mg/kg propofol or 0.5 mg/kg alfaxalone followed by 0.25 mg/kg midazolam IV. Then titrate propofol or alfaxalone to achieve tracheal intubation. The inclusion of medetomidine in these protocols assumes no underlying cardiovascular disease is present.
Please provide oxygen by mask during sedation.
DURING HOSPITALISATION
If patients are hospitalised the use of medication to reduce the emotional impact of that stay can be considered. Options include:
· Trazodone 4-6 mg / kg up to bid (NB different dose from pre vet visit protocols)
OR
· Alprazolam 0.01-0.1 mg/kg PO
During hospitalisation attention must also be paid to the use of dog friendly interactions and management techniques and the emotional health of the patient should be monitored alongside its physical health reason for hospitalisation.
Medication protocols for emotionally challenged cats during veterinary visits and procedures from Zero Pain Philosophy and Behavioural Referrals Veterinary Practice
This protocol is designed to be used in conjunction with a cat friendly approach to managing the individual patient. Emotional assessment of the patient should have been carried out as part of that management process. Where necessary advice regarding the emotional health of the patient through consultation with a veterinary colleague working in behavioural medicine may be sought.
PRE-VISIT COMPONENT OF PROTOCOL
Give oral anxiolytic at home 1-3 hours prior to visit. Options:
· Pregabalin 5 mg/kg PO 1-2 hours prior to leaving home (NB Bonqat® is a licenced veterinary product in some countries) OR
· Gabapentin 20 mg/kg PO 2 - 3 hours prior to leaving home OR
· Trazodone approx. 10 mg/kg PO 2 hours prior to leaving home. In exceptional cases where gabapentin alone is not effective it is possible to combine trazodone with gabapentin using the following recommended dose:
• Trazodone 5 - 10 mg/kg PO and gabapentin 20 mg/kg PO
NB Gabapentin and pregabalin are schedule 3 medications and subject to relevant prescribing regulations. Liquid preparations can facilitate administration of the medication and accuracy of dosing.
In cases where patients are attending consultations only or routine blood sampling the pre- visit component may be sufficient alone. For particularly challenged patients and those undergoing procedures it may be appropriate to combine with sedation protocols on arrival at the practice.
The presence of acute or chronic pain must always be considered as a potential factor when patients are exhibiting challenging behaviour. The use of gabapentin as part of the pre visit protocol may be of particular benefit for patients with a pain component, provided they are gabapentin naïve. Another option for feline patients is the use of transmucosal buprenorphine, either at home the night before or on arrival. The use of EMLA or cold spray preparations should be considered before embarking on procedures such as venepuncture.
ON ARRIVAL AT THE PRACTICE
Intramuscular option – ASA I/II patient
Medetomidine 0.02-0.04 mg/kg and opioid (butorphanol 0.2mg/kg OR methadone 0.2mg/kg OR buprenorphine 0.02mg/kg depending on pain anticipated/present)
Wait 5 minutes for effect then give ketamine 3-5 mg/kg
Intramuscular option – ASA III+ patient (undetermined cardiac disease, hyperthyroid)
Alfaxalone 2 mg/kg and butorphanol 0.2 mg/kg and midazolam 0.2 mg/kg
Subcutaneous option ASA III+ patient
Alfaxalone 3 mg/kg and butorphanol 0.2 mg/kg. Sedation at the 45 minute time point was adequate to allow the cat to be tabletted in one study.
Please provide oxygen by mask during sedation
DURING HOSPITALISATION
If patients are hospitalised the use of medication to reduce the emotional impact of that stay can be considered.
• Gabapentin 5 – 10 mg / kg up to BID (NB different dose from pre vet visit protocols)
During hospitalisation attention must also be paid to the use of cat friendly interactions and management techniques and the emotional health of the patient should be monitored alongside its physical health reason for hospitalisation.
When gabapentin has been used as part of a pre vet visit medication protocol or for cats during hospitalisation caregivers must be informed of the ongoing impact on mobility and spatial awareness. Cats must be kept inside for at least 8 hours after the last administration of gabapentin.
Dr Matt Gurney BVSc CertVA PgCertVBM DipECVAA FRCVS
RCVS and EBVS® European Specialist in Veterinary Anaesthesia & Analgesia
Dr Sarah Heath BVSc PgCertVE DipECAWBM(BM) CCAB FHEA FRCVS
RCVS and EBVS® European Specialist in Veterinary Behavioural Medicine
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